Case Study

Scenario

E.M., a 5-month-old girl, is brought to the emergency department (ED) with respiratory distress,
hypoxia, and fever. Her parents state that she has had mild cold symptoms for a few days. She
has breastfed poorly over the last few days, with a decreased number of wet diapers. You take
her vital signs and complete an initial assessment.

Chart View

Vital Signs
Blood pressure 130/72 mm Hg
Respiratory rate 83 breaths/min
Heart rate 188 beats/min
Temperature 38.4 ° C (101.1 ° F)
SpO2 88% on room air
Weight 8 kg

Initial Assessment
Alert, fussy; consoles briefly; anterior fontanel soft and slightly
Neurologic
depressed
Cardiovascular Tachycardia; capillary refill less than 3 seconds
Upper airway congestion; coarse cough; tachypnea, transient
Respiratory bilateral wheezing; coarse rhonchi and slightly decreased
breath sounds at bases; mild intercostal retractions
Gastrointestinal Positive bowel sounds; last bowel movement yesterday
Decreased urine output (per history); no urine output in last
Genitourinary
4 hours
Skin No rashes; slightly flushed
Other Mucous membranes “sticky”; decreased tearing

Emergency Department Orders

Acetaminophen (Tylenol) 80 mg PO for fever × 1 dose
Start IV and administer normal saline (NS) bolus 20 mL/kg IV bolus over 30 minutes
Oxygen to keep saturation greater than 93%
Nebulizer trial of albuterol (Proventil) 2.5 mg STAT × 1 dose

1. Review the standing ED orders. Prioritize your interventions and give rationales.

2. Based on E.M.'s vital signs and assessment, what diagnostic tests would you anticipate?
3. Calculate how much 0.9% Normal Saline E.M. will receive as a bolus.

Case Study Progress

E.M. begins coughing and has copious nasal secretions. You provide nasopharyngeal suctioning
and obtain a large amount of thick secretions. She is allowed to recover and is reassessed. The
respiratory rate and retractions have not changed significantly. Her breath sounds are less coarse
but are diminished in the bases. The SpO2 is now 92% to 93% on 1.5 L oxygen. After E.M.
settles, her mother asks whether she can feed her because she has not eaten much for the past few
days. You tell her that with a current respiratory rate of greater than 65 breaths/min, she should
not be fed.

4. What is the rationale for holding feedings?

5. When E.M.'s respiratory rate decreases, what teaching would you provide the parents
concerning feeding?

Chart View

Medication Administration Record

● Normal saline drops to nares q3h with suctioning

● Acetaminophen (Tylenol) 80 mg PO q4h prn for fever
● Amoxicillin (Amoxil) 45 mg/kg/day PO tid × 7 days

6. You are reviewing the medication administration record. Which order(s) would you
question? Explain.
Case Study Progress

E.M.'s mother calls you to the room because her baby is “not right.” You note E.M.'s respiratory
rate is 23 breaths/min, and the retractions have increased. The SpO2 is 89% on 1.5 L of oxygen.
She is pale and listless and does not cry with stimulation.

7. Why is the respiratory rate significantly lower even though other signs of respiratory distress
have increased?

Case Study Progress

You are concerned and call the rapid response team. You check her SpO2 again with results of
88%. The senior resident orders a portable chest x-ray (CXR) examination and capillary blood
gas (CBG). The CXR is consistent with bronchiolitis with atelectasis.

Chart View

Capillary Blood Gas

pH 7.31

PaCO2 72 mm Hg

HCO3 29 mEq/L

PaO2 57 mm Hg

8. Interpret E.M.'s CBG results

Case Study Progress

E.M. is transferred to the pediatric intensive care unit (PICU) and placed on a continuous
positive airway pressure (CPAP) machine. You know from experience that patients are usually
on CPAP for a couple of days before they are ready to be taken off and continue to improve until
they are ready for discharge. You explain this to the parents, who are very distressed.

9. What resources might you seek for E.M.'s parents during this unanticipated change in status?

Case Study Progress

After 2 days in the PICU, E.M. is transferred back to your unit. You note that she is taking
increased oral fluids and requiring less suctioning. Her SpO2 is 96% to 98% on room air. As you
are preparing the parents for discharge, they want to know how they can prevent this in the
future. They ask whether there is a “shot” E.M. can get to avoid getting this again.

10. How would you address their concerns?

11. E.M.'s parents ask you for instructions about the treatment of cold symptoms if E.M.
develops them again. Which answer is your best reply?

a. “Over-the-counter cough suppressants may be safely administered at night.”

b. “If a fever is present, you can treat the fever with baby aspirin.”
c. “Saline nose drops and bulb suctioning can be done before feedings.”
d. “You do not need to worry if she is not drinking; intake should improve in a day or so.”